Your Direct-To-Consumer Pelvic Floor

When I got pregnant in 2018, my prenatal yoga instructor stressed the importance of doing squats, and I had read that Kegels were vaguely important, but otherwise, no one discussed my pelvic floor with me before, during, or after my pregnancy. My obstetrician was concerned with my amniotic fluid level (which was low toward the end of my pregnancy), not with my pelvic floor muscles. She cleared me to drive two weeks after my unplanned C-section (I’d been induced thanks to the low amniotic fluid; it didn’t work), and at my six-week postpartum appointment, she said I could resume all normal activities. And that was that. To be honest, I didn’t even know what questions I should be asking, and I (naively) assumed that because I’d had a C-section, that I didn’t have a need for pelvic floor therapy.

Indeed, until now, perhaps the biggest hurdle for people with pelvic floor problems was the lack of awareness and the stigma. A 2012 study found that only no more than 25% of women who suffered from urinary incontinence had sought treatment, and as a more recent study concluded: “At an individual level, barriers to care-seeking include embarrassment, lack of knowledge of treatment options, feeling that the symptoms are not bad enough, and unwillingness to bring it up independently of being asked by their [health care provider].”

Today, not even five years later, information about the pelvic floor is suddenly everywhere. In the past five years, interest in “pelvic floor therapy” has more than doubled, according to trend data company Exploding Topics. But that interest doesn’t necessarily translate to appointments with licensed therapists, much less relief from pelvic floor disorders. In the American health care system, support is not always available — insurance might not cover treatment; your preferred provider might not take insurance; waitlists are often long — and into this vacuum have stepped several companies offering devices for people to help their pelvic floor issues.

The need for pelvic floor therapy seems higher than ever — both because of increased awareness and the specific nature of motherhood in late capitalism.

The Elvie Trainer, which launched in 2015, was an early entry to the app-enabled pelvic device space, but the field has since gotten much more crowded. Now someone suffering from urinary incontinence or painful sex or constipation or any of the many other symptoms of pelvic floor issues might first seek out answers from pelvic floor influencers on social media — private Facebook groups, TikTok, and Instagram, in particular — and then buy one of the many pelvic floor-related devices on the market, like an Elvie Trainer (“Take charge of your pelvic floor with expert-designed care from home”) for just $199, Bluetooth-enabled app included.

Then there’s the Perifit, which uses games in its app to strengthen your pelvic floor. (Perifit’s website: “That’s right! You get to play video games with your vagina.”) But it’s unclear whether the gamification of the Kegel is necessarily a positive development, as one reviewer on its website commented: “I really like my perifit. It has improved my slight stress incontinence in just three weeks. However, i’m not a fan of how fast you get to the next level. I’m on level 9 now, even though i was having quite a bit of trouble managing the previous levels and it leaves me quite frustrated. I would really prefer to be able to go to the next level when I actually feel ready. Playing isn’t really that fun when you’re constantly making bad scores.” If playing smartphone games with your vagina doesn’t appeal but you still want a device, there’s an almost dizzying array of options at price points ranging from around $60 to $500, including the iStim Kegel Exerciser, the Intimina KegelSmart, the TensScare iTouch Sure Pelvic Floor Exerciser, and the Innovo Kit With Incontinence Shorts.

All of the pelvic floor therapists I spoke to for this story cautioned against using a device without first consulting a therapist, emphasizing that because everyone’s pelvic floor issues and needs are different, a device can possibly do more harm than good. One of the main issues with these devices is that most people assume that their pelvic floor muscles need strengthening, when in fact the issue could be that they need to learn to relax. In this case, a device designed to strengthen your pelvic floor would do more harm than good. “Where I see them best being utilized are the devices that you can hook up to an app on your phone or your computer where it gives you feedback,” says Laurel Proulx, Ph.D., a researcher and licensed pelvic health therapist. “I think those can be helpful for individuals who really have no awareness of their pelvic floor. Generally beyond that, I think that’s where it ends. I think if people have awareness of their pelvic floor, then we move on to other things.”

Those other things can include manual therapy, trigger point therapy, and electrical stimulation, as well as Kegels. “It’s much more integrated with our overall movement rather than an isolated exercise because our pelvic floor doesn’t work in isolation and it doesn’t work consciously. It’s not like a bicep,” says Proulx. In other words, you really do need a trained expert.

One recent study estimated that there are around 10,000 pelvic floor therapists and 40 million people who need treatment in the U.S.

And yet, the need for pelvic floor therapy seems higher than ever — both because of increased awareness and the specific nature of motherhood in late capitalism. Modern-day demands on birthing people as also having an effect on people’s pelvic floors, notes Virginia-based pelvic floor therapist Ann Nwabuebo. “We go back to work a lot sooner after birthing a child,” she says. “Our bodies do the best they can to kind of spring back into the swing of things faster than they’re actually healing, and the support system for us is not quite the same. And a lot of women and birthing people are having kids a lot later in life as we pursue our careers, and that does have an impact on the body and how tissues are healing. So we do end up having to need more support.” While there is no national database of pelvic floor therapists, one recent study estimated that there are around 10,000 pelvic floor therapists and 40 million people who need treatment in the United States.

While there may be a lack of actual providers, at least there is now access to information. It’s no longer an unspeakable issue. Janelle Howell is a licensed pelvic physical therapist in Chicago who goes by Vagina Rehab Doctor on Instagram, where she has nearly 200,000 followers. Until 2020, Howell mostly used her Instagram for posts about travel, but when the pandemic hit, she began posting about her area of professional expertise, and soon found that her frank, informative posts (like “What Does Pooping Have to do With My Vagina?”, graphics of perineal tears, and “9 Pelvic Floor Exercises for Doggy Style”) had struck a chord.

“It’s become a platform for me to empower people,” she tells me. “Because a lot of times we’re told ‘Oh, well, this is just part of being a woman — after having a baby, you’ll just leak’ or ‘Painful sex, there’s not much you can do about that.’ So many different things that really make us feel like we don’t have any power. You don’t need to doubt yourself if you want to be out of pain, if you want to run without leaking, if you want to experience sex that actually feels good — these are normal life goals that people should feel validated in.”

It’s possible there will come a day when getting pelvic floor therapy is just another item on the physical health checklist, like treating high blood pressure or getting a mammogram. And hopefully, as the landscape continues to evolve, access will become just as much of a priority as awareness: affordable care that is covered by insurance, shorter waiting lists, more providers, more questions and more referrals at the six-week postpartum appointment. After all, doesn’t your pelvic floor deserve it?

Doree Shafrir writes the “Now We’re Talking” newsletter for Substack. She is the author of the memoir Thanks For Waiting: The Joy & Weirdness of Being a Late Bloomer and the novel Startup. She is also the co-host of the podcasts Forever35 and Matt & Doree's Eggcellent Adventure. For Romper, she has written about Silicon Valley’s efforts to build a better baby formula, profiled Mandy Moore, and documented “respectful parenting” gurus on Instagram.